Burnout among Healthcare Providers of COVID-19; a Systematic Review of Epidemiology and Recommendations

Introduction: In the current systematic review, we intended to systematically review the epidemiology of burnout and the strategies and recommendations to prevent or reduce it among healthcare providers (HCPs) of COVID-19 wards, so that policymakers can make more appropriate decisions. Methods: MEDLINE (accessed from PubMed), Science Direct, and Scopus electronic databases were systematically searched in English from December 01, 2019 to August 15, 2020, using MESH terms and related keywords. After reading the title and the abstract, unrelated studies were excluded. The full texts of the studies were evaluated by authors, independently, and the quality of the studies was determined. Then, the data were extracted and reported. Results: 12 studies were included. Five studies investigated the risks factors associated with burnout; none could establish a causal relationship because of their methodology. No study examined any intervention to prevent or reduce burnout, and the provided recommendations were based on the authors' experiences and opinions. None of the studies followed up the participants, and all assessments were done according to the participants’ self-reporting and declaration. Assessing burnout in the HCPs working in the frontline wards was performed in four studies; others evaluated burnout among all HCPs working in the regular and frontline wards. Conclusion: Paying attention to the mental health issues, reducing the workload of HCPs through adjusting their work shifts, reducing job-related stressors, and creating a healthy work environment may prevent or reduce the burnout.


Introduction
Burnout is a global health concern that affects physicians, nurses, and other healthcare providers (HCPs), and has been the focus of recent debates (1, 2). World Health Organization (WHO) recognized burnout as a syndrome and based on International Classification of Diseases (ICD)-11 it is defined as: "Burnout is caused by chronic stress in the workplace which is not managed successfully and is characterized by three dimensions: 1) feeling of energy loss or fatigue; 2) increased mental distance from one's job or negative feelings or pessimism about the job; and 3) reduced professional ef-the onset of the pandemic, HCPs, especially those working at emergency departments and departments that were specially devoted to treat COVID-19 patients, have faced a wide range of occupational stressors and a higher than usual workload; prolonged wearing of personal protective equipment (PPE), excessive heat caused by extra clothes, dehydration, poor nutrition, lack of enough sleep, and fatigue have predisposed HCPs to burnout (9). On the other hand, constant exposure to the suffering and death of patients and the constant need to sympathize with patients and their family members have caused extra mental health problems (10-13). With the onset of the pandemic, various studies have examined burnout among HCPs working in COVID- 19 wards (11-15). In the current systematic review, we intended to systematically review the epidemiology of burnout and the strategies and recommendations to prevent or reduce it among HCPs of COVID-19 wards, so that policymakers can make more appropriate decisions.

Data sources
In this systematic review of the literature, we searched MED-LINE (accessed from PubMed), Science Direct, and Scopus electronic databases from December 01, 2019 to August 15, 2020, using MESH terms and the following keywords: ("COVID-19" OR "COVID19" OR "Corona" OR "Coronavirus" OR "SARS-CoV-2") AND (burnout) AND ("Medical Staff" OR "Health Personnel"). Google Scholar and researchgate.net were also used to access other articles in English. To ensure literature saturation, the reference lists of the included studies or relevant reviews identified through the search were scanned.

Study eligibility criteria
We focused on the studies on the epidemiology of burnout and the strategies and recommendations to prevent or reduce it among HCPs. Articles were excluded if they were not relevant to the epidemiology of burnout, or to strategies and recommendations to prevent or reduce it, or were performed before the COVID-19 pandemic, through reading the title and the abstract.

Participants, and interventions
The target population were all HCPs of COVID-19 wards (physicians, nurses, etc.). Moreover, we wanted to find which solutions or interventions are effective in preventing or reducing burnout among them.

Study appraisal and synthesis methods
Then, full texts of the studies were evaluated by two authors (MS, RSM); they decided whether these met the inclusion criteria, independently. The quality of the studies was determined according to the American Academy of Neurology cri-teria for classification of evidence in causation studies (16). They resolved any disagreement through discussions, and finally the articles were selected based on consensus. Neither of the authors were blind to the journal titles or to the study authors or institutions. The following data were extracted from the included studies and recorded in a Microsoft Excel sheet, 2016: study authors, methods, main findings, and recommendations. This systematic review was reported according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement (17) (figure 1).

Discussion
In this systematic review, twelve studies were found, which were about the epidemiology of burnout, or strategies and recommendations to prevent or reduce burnout among HCPs of COVID-19 wards. Most of the studies used the MBI tool to evaluate the burnout. MBI is one of the most common tools and the gold standard to measure burnout among staff, based on self-reporting using a Likert scale (33, 34). Our results showed that none of the studies were interventional, and none of them followed the participants. Although we categorized the related factors in 5 areas, most of the studies focused on the workplace conditions and organizational behavior as well as mental health status. The results showed that burnout among HCPs working in the frontline wards was assessed in four studies; others evaluated burnout among all HCPs working in the regular and frontline wards. There are conflicting findings concerning the rate and epidemiology of burnout among HCPs working in COVID-19 wards. A study on 1,153 Italian healthcare professionals found that those who were directly involved with COVID-19 patients experienced higher levels of job-related stress, somatic symptoms, and burnout. Burnout, particularly emotional fatigue and depersonalization, was directly associated with the experience of at least one somatic symptom (such as changes in eating habits, difficulty sleeping, and muscle tension) during the past 4 weeks (12). In another study, 40.3% of the HCPs of COVID-19 wards, particularly nurses (45%) and physicians (31%), experienced burnout (11). A study from Turkey found that burnout rate was higher among the staff of emergency departments, ambulances, and intensive care units (ICUs), who were in the first line of combat against COVID-19 (15). One study reported that trainees who were exposed to COVID-19 patients had higher rates of burnout compared to those in the non-exposed group (18). Another survey found that nurses had experienced the following: 60.5% emotional fatigue, 42.3% depersonalization, and 60.6% decreased self-adequacy (19). In contrast to the above-mentioned studies, one study reported that those working in COVID-19 wards had significantly lower levels of burnout compared with physicians and nurses working at other wards; the former HCPs felt higher levels of control over their work, they were more aware of the preventative policies and procedures, and were supported by the healthcare system. Furthermore, the staff working at the COVID-19 wards felt more valued (14). Another study on first-line residents (e.g., emergency medicine, radiology, and ICU), showed that 76% of them had burnout, which was lower compared to that among residents at other wards (rate of 86%) (9). Further studies are needed to clarify the frequency of burnout among HCPs working under different circumstances during the COVID-19 pandemic.
Various studies have mentioned several associated factors for burnout. HCPs may experience higher levels of workload, are engaged with strict organizational regulations, have less time to deal with their job challenges, and the knowledge in the field is continuously evolving (35). Furthermore, during the COVID-19 pandemic, an uncertain prognosis of patients; lack of enough medical resources for diagnosis, treatment, and prevention; problems related to protecting healthcare providers from getting infected due to inadequacy of PPE; rapid change in public health-related policies; decreased income and economic recession; and conflicting information announced by officials have been major stressors that certainly may increase the risk of burnout (36). Health managers and policymakers' awareness of burnout is important in prevention and appropriately addressing it. A meta-analysis (2018) showed that resilience reduces burnout (37). Therefore, during the COVID-19 pandemic, it is necessary to recognize the factors associated with burnout and also identify the ways to deal with them. Different studies have suggested various methods to prevent or reduce burnout. These methods may be divided into two categories: individual methods and organizational (system-based) approaches (9, 13, 14,19,24,26). Some studies reported that women have higher levels of emotional fatigue than their male counterparts (12, 26). Also, men may experience fewer somatic symptoms (12). One study showed that being a woman is a risk factor for experiencing burnout among HCPs working in acute critical care division (11). On the other hand, another study reported that burnout was not associated with gender (37). It was also reported that burnout was more common among HCPs who had a child or a family member older than 65 years or with a chronic illness, due to fear of transmitting the infection (15). On the other hand, maintaining physical and emotional hygiene is an effective strategy to reduce burnout. Happiness, regular exercise, drinking water, and having a good rest may increase the immunity and keep the person away from the disease (11, 24, 25, 38) (11, 25, 38). Therefore, simple measures such as providing a resting facility and the possibility of taking a shower at the workplace may be effective (38, 39). Interaction with family members and loved ones (40) and social support by the family (19,29,30) are other effective measures in reducing burnout. One of the important factors associated with burnout is the mental health status (33). Burnout is a multi-dimensional response to job stressors. These stressors may be physiological, emotional, or interpersonal (41). Burnout may lead to increased rates of psychological problems, suicide, and substance use among HCPs (20). Obligation to provide selfless service to the community may lead to neglecting their own physical, mental, social, and emotional health among HCPs (10). Improving work schedules, promoting self-management, teaching physical, mental, and emotional self-care, and starting mindfulness-based stress control activities are among the effective techniques to prevent or reduce burnout (10, 13, 28). Providing counseling and support systems, as well as holding support meetings for COVID-19 treatment teams are other effective interventions (12, 26,27,35). HCPs should be heard, protected, prepared, and supported by their organizations. Digital technologies may be a causative factor for burnout and also may be used to reduce burnout. In recent years, the role of digital technologies in providing health services has expanded. During the COVID-19 pandemic, registry systems and electronic health record (EHR) systems have been used widely (32). These systems should serve physicians and HCPs, but at the same time, EHR systems monitor physicians' performance and their qualifications. Therefore, instead of spending time to provide health services to patients, physicians have to enter the data into the EHR; as a result, they spend more time at the hospital and stay away from their families; these may cause burnout (6). On the other hand, digital technologies, such as mobile applications and social media, can be used to provide mental health services and increase the empowerment of HCPs (32). Talking about concerns with colleagues and friends, which can be achieved through web-based social media, is an appropriate way to reduce the stress (9). Also, the use of digital communication platforms, such as WhatsApp, allows physicians to access each other more easily, share information, and have immediate access to valid and updated information. Burnout is often influenced by organizational behaviors. Changing the behaviors that may cause burnout and adopting healthier behaviors is essential. This can only happen if there are organizational interests to meet these challenges (10). A meta-analysis showed that workplace interventions were directly associated with a reduction in the burnout scores (35). Therefore, along with other individual measures, interventions to improve the workplace and organizational environment have significant effects on promoting work culture and relieving workplace stress (9, 13, 20, 24, 26). The number of work experience years, the number of working hours per week, more night shifts per week, the frequency of working over the weekends, having a coworker who is suspected or has a confirmed diagnosis of COVID-19, and the number of staff members in each team may be associated with burnout (24,42). Organizational strategies to create a capable environment to reduce burnout could include the following interventions: improving workflow management, organizing services with an emphasis on reducing workload, improving communication skills, arranging discussion meetings, increasing interoperability, providing the opportunity for having adequate rest and exercise, holding workshops on coping skills, decreasing the clinical demand via schedule changes, and increasing teamwork (19,25,31,32). Developing clear and up-to-date guidelines and protocols for different situations, as well as practical training about protective interventions are among interventions that may increase the sense of safety, assurance, and control (9, 24,26,31). Finally, the WHO has stated that an imbalance between effort and reward may lead to feelings of injustice or incompetence, which in turn leads to the feeling of anger that may be directed against the supervisor or co-worker (43). To reduce burnout, there should a balance between giving and taking, stress and relaxation, and work and home (44). Burnout may be associated with social support outside the family (19). Social interactions of HCPs are effective in reducing burnout (29,30). Wearing face protection equipment may lead to deterioration of the interpersonal relations and interactions due to difficulty in face recognition. To solve this problem, it was recommended to install photos of the staff on their clothes (9).

Conclusion
Awareness of healthcare managers and policymakers from burnout among HCPs, who are working at COVID-19 wards, and administration of appropriate solutions to prevent or reduce the burnout are necessary. Paying attention to the mental health issues, reducing the workload of HCPs through adjusting their work shifts, reducing job-related stressors, and creating a healthy work environment may prevent or reduce burnout. Future, large and multicenter studies on HCPs of COVID-19 wards are necessary to identify the frequency, associated factors, and effective preventative strategies of this phenomenon.

Implications of key findings
The available early-stage and low-quality evidence cannot provide convincing support in favor of or against a particular recommendation to prevent or reduce burnout in HCPs of COVID-19 wards. This is mainly because of the heterogeneity with respect to the participants and applied tools, different suggestions, absence of any intervention, and not following the participants. However, the results of this study showed that the policymakers can take measures to prevent or reduce burnout in the five introduced areas. However, more large and interventional studies are highly recommended to identify effective solutions and measure their effectiveness.

Standard Protocol Approvals, Registrations, and Patient Consents
The Shiraz University of Medical Sciences Institutional Review Board approved this study and systematic review (IR.sums.med.rec.1399.322).

Systematic review registration number
The review protocol was not previously registered.

Availability of data and material
Data sharing is not applicable to this article.

Ethical issues
This study was approved by the vice-chancellor of research and technology (Grant No. 23376), as well as the local Ethics Committee (IR.sums.med.rec.1399.322) of Shiraz University of Medical Sciences.

Conflict of interest
There is no conflict of interest. Cross-sectional study to compare the frequencies of burnout syndrome among 50 medical residents working in the frontline wards (30 emergency, 10 radiology and 10 intensive care unit) and 50 medical residents working in normal hospital wards (25 surgery, 15 obstetrics and gynecology, 10 orthopedics) during the COVID-19
• Burnout was significantly more frequent in medical residents in normal wards (86%) compared to medical residents working in frontline (76%).
• Effective measures must be taken at the institutional and individual levels.
• Balance between giving and taking, stress and relaxation, and work and home. • The shift program must be planned in a way that respects the epidemiological timing (incubation period or quarantine time Cross-sectional study to compare the frequency of burnout between physicians and nurses working in usual and frontline wards, including 190 participants, 96 of whom worked in the frontline wards.
• The frequency of burnout was significantly lower in the frontline group than in the usual wards group in the past 2 months during the COVID-19 pandemic. • HCPs in usual wards may have perceived less control over new policies and procedures. • HCPs in frontline may have felt closer to the key decision makers and have had access to more timely and accurate information. • Much attention is paid to those who work directly with infected patients. • 76% of participants from the frontline strongly disagreed or disagreed that he/she felt more burnout now compared with before the COVID-19 pandemic. • Participants continuing to work in their usual wards were more worried about themselves or a family member becoming infected. -III

9
Archives of Academic Emergency Medicine. 2021; 9(1): e7 Cross-sectional study to compare anxiety and burnout levels between HCPs working in emergency service with other HCPs in Turkey during the COVID-19 pandemic.
• The burnout score of pandemic area and the intensive care unit (ICU) workers were similar to those in the emergency service and ambulance. • The emotional score of the emergency and ambulance workers was higher. • The burnout score of pandemic fields and ICU workers was significantly higher than radiology, laboratory, and office workers. • Burnout was higher in women and HCPs who lived with their relatives >65 years of age. • Burnout in doctors and nurses was higher than other HCPs. • PPE was associated with higher burnout score. • The exposed group had a higher level of burnout compared to the non-exposed group. • Multivariate regression showed that trainees who were exposed to COVID-19 patients reported significantly higher burnout.
• Normalize feelings of emotional distress and reduce stigma by encouraging discussion of the stressors of clinical work. • Provide programs that increase accessibility to mental health services for trainees. • Provide childcare options for married trainees at night shifts and long hours duties.

III Hu D, et al. (2020)(19)
Cross-sectional study to evaluate mental health (burnout, anxiety, depression, and fear) and the associated factors among 2,014 frontline nurses who were caring for COVID-19 patients in China.
• About half of the nurses reported moderate and high job burnout, 60.5% emotional exhaustion, 42.3% depersonalization, and 60.6% personal accomplishment. • Emotional exhaustion was positively correlated with skin lesion and negatively correlated with self-efficacy, resilience, intra-family social support, and extra family social support. • Depersonalization was negatively correlated with resilience, intra-family social support, and extra-family social support. • Personal accomplishment was positively correlated with self-efficacy, resilience, intra-family social support, and extra-family social support.
• Improve mental health • Build self-efficacy and resilience • Provide sufficient social support • Ensure frontline work willingness III  (20) A comprehensive study to provide a conceptual paradigm for understanding the relationship between burnout, acute stress disorder, and post-traumatic stress disorder (PTSD); as well as an evidence-based review and recommendations for system-based interventions that may reduce physicians' stress.
• Increased exposure to stress and trauma due to acutely increased workplace stress resulting from the pandemic, combined with underlying baseline burnout, may result in rising rates of PTSD among physicians.
• Institutional and individual interventions for addressing burnout and promoting wellness: • Decreased workload, improved work schedules and electronic health record, mindfulness-based stress reduction, and personal coaching. • Physicians enjoy highly actionable tools that require minimal time to learn and implement (micropractices). • Micropractices only require a few seconds to a few minutes to implement.
Although many structural and cultural changes are needed, micropractice is a suitable strategy to prevent burnout. • Suitable times for micropractices: o Hand hygiene for self-awareness and self-management. o When logging into the electronic health records. o Hearing the concerns of family or friends o When waiting at a red light o Before answering e-mails or texts o When brushing teeth • Take a moment to name one's emotions, especially challenging emotions. • Write down three good things. • Share the personal practices around burnout prevention and wellness in a workshop setting. • Do diaphragmatic breathing.
The wellness of HCPs is a spectrum, from engagement to burnout; that individual characteristics, experiences and organizational factors can influence one's position on this spectrum.
Interventions to decrease burnout: • Organizational level: 5 principles ("hear me," "protect me", "prepare me", support me" and "care for me"). • "CREATE" (Compassion and Resilience Team-building): pairs a psychosocial services professional with clinical managers to offer support and implant low-dose interventions into clinical teams using a coaching and psychological first aid model. • A toolkit with information on accommodation, grocery delivery, safety, coping and mental health resources. Janeway D (2020) (28) To describe the role of psychiatry in treating burnout among nurses during the COVID-19 pandemic  (29) To describe the impact of the COVID-19 pandemic on medical education and resident burnout in a postgraduate program.